Hopelessness and isolation are major factors for suicide: Psychiatrist

Ashit Sheth, one of India's best known psychiatrists, tells Aditi Phadnis and Pavan Lall what it means to suffer from depression and how to deal with it.

Depression is a highly misunderstood condition. Can you explain what it is?

Depressive disorders have varied manifestations—individuals who suffer from depression may experience complaints of pain or some physical symptoms like weakness, sleeplessness, or breathlessness. Doctors attending to them tend to respond more to physical symptoms and miss underlying depression. Doctors during their curriculum do not get adequate exposure in detecting and treating emotional disorders. Here’s the thing: Surveys worldwide have established that depression is present in 10-15 per cent of the global population. Various studies in general hospitals and conducted by primary physicians showed depression is underdiagnosed and undertreated. These patients who have “unexplained physical symptoms” are not treated for their underlying depression. So I had one patient, Anuradha (name changed for privacy) who was a married mother of one, and came to me with complaints of persistent headaches for six months. She said, "these headaches have ruined my life. My head feels like a water-filled balloon that is going to burst at any moment. Mostly, my mornings are the worst, and by evening, the headache reduces. Sometimes I feel like ending my life. I have become useless and a burden to the family." She had come to me after consulting several neurologists and getting the symptoms investigated thoroughly. When a friend told her she should consult a psychiatrist, she lost her temper as she said "the headaches are not in my imagination and I do not need a shrink." Nevertheless, running out of solutions and out of desperation, she reluctantly agreed to see a psychiatrist.

The psychiatrist, I, explained to her that many patients have physical symptoms, commonly related to pain. These so-called "unexplained medical symptoms" are due to the underlying disease of depression. I had to explain to Anuradha at length that the mind and body are deeply interconnected, and pain is felt in mind as well as the body. In her case, headaches were one painful symptom related to depression. In addition to her headache, she did not participate in enjoyable activities and outings. Her appetite, weight, and libido were all reduced. Also, she would feel unduly tired and exhausted. On occasion, she mentioned feeling useless and sometimes even said she felt like dying. When you experience depression, certain neurotransmitters like serotonin and norepinephrine are reduced, and antidepressants and psychotherapy correct this imbalance. As expected, Anuradha responded well to antidepressant medications and psychotherapy.

Our feelings are continually changing and interacting with outside events. Your emotions may reflect inner temperaments — some days, without reason, you feel happy some days are gloomy without reason. These feelings are temporary, and we get along with our lives without any problems. The thing is that it’s important to remember that normal fluctuation of moods  are not a symptom of depression and happens to us all.

So many of us feel sad, helpless and just unable to cope with it all, sometimes. Does that mean we’re suffering from depression? How do you recognise it?

Clinical depression is a set of symptoms that form a cluster or a syndrome, consisting of pervasive and a long-lasting depressed mood without any significant reason. Pathological depression is associated with loss of drive, poor concentration, and memory, inner unrest, severe anxiety leading to immense restlessness. Some may show slowness of mental and physical faculties. A person may feel frail and tired without any reason. He or she experiences diminished appetite, and weight loss. Depression is also associated with difficulty with decision making and carrying out tasks that a person could do before becoming depressed. Depressive states also affect an individual's intellectual functioning, which will return to normal on treatment. His thinking is revolving around guilt, suicidal ideations, helplessness, and hopelessness. He thinks that his future is dark and has no hope of recovering. He withdraws from friends and social activities as he loses deriving any pleasure from them and experiences what is called anhedonia. This depression, I repeat again, is distinct from temporary mood changes faced in ordinary life.

A depressed person’s thinking gets contaminated with distorted thoughts, and coloured with his depressed feeling. Other types of depression may need a different approach to treatment.

Many patients who are diagnosed with the problem still self-harm. Many of these are famous personalities, like Anthony Bourdain or Sushant Singh Rajput. Why is it so?

Self-harming behaviour is prevalent in our society and ranges from excessive drinking, gambling, use of recreational drugs, and unprotected sexual activities. They are para-suicidal activities, and people who engage in them disregard harm to themselves or their families. Some borderline personalities may even resort to self-inflicted cigarette burns, cutting, and piercing. Their actions are not genuinely suicidal, but they divert their attention and provide relief from boredom or painful thoughts. Many individuals who gain rapid success have a “creative edge”. These creatives have underlying bipolar traits, or they have bipolar patients in their families. They are individuals with high functioning abilities. They can work long hours with little rest and achieve success in their life. With some crises in their career or personal life, they get depressed, and they may not respond to conventional antidepressants. Their depression mimics bipolar depression, which requires different management and is associated with a high suicide rate. Many successful people have initial low self-esteem, which pushes them to work harder. Despite achieving phenomenal success, their core is still shaky and lingers nervously at every performance.

Look at the writer Ernest Hemingway. The author of the century, he won the Pulitzer and the Nobel Prizes. Famous and celebrated, his life was full of adventures but he was socially actually quite aloof. He had several marriages and multiple affairs but just could never get very close to anyone. Suicidologist Roland Paris described this as being indicative of having a “suicidal core”.

Hemingway had his first episode of depression at the age of 52. He was treated at Mayo Clinic, and was bothered about his inability to work after treatment. At the time, he wrote to his friend, "My work is done, why wait?" Hemingway killed himself with a shotgun in 1961. He had once commented to his biographer that a man could be destroyed but not defeated. In his case, his family had many cases of suicide, including his father, and depression ran in his family.A list of celebrities who have resorted to suicide is quite long. In part, success leads them to an ivory tower where life becomes lonely, or they were always alone, and creative pursuits gave them some avenue to get recognised. But the pain of loneliness is part and parcel of their daily existence. Cognitive therapy gurus say isolation and hopelessness are two major underlying factors for leading a person to suicide. Some people resort to alcohol, some to cocaine, some to pain killers like Michael Jackson. All these substances and even suicide provide relief of psychological pain or “psyche ache”. About one in 100,000 commits suicide. Worldwide, suicide attempt is prevalent among women and men but successful suicides are more common in males. In India, the rate is of suicide is 15 in 100,000; it is the highest globally. Also, in India, the male to female ratio is equal for successful suicide, and the most frequent mode of committing suicide is the ingestion of agricultural and household insecticide. China had similar problems related to pesticides, and their suicide rates were equal to India. Believe it or not, changing the quality of pesticide has brought down the suicide rate to International level one in 100,000.

The immediate family of a person suffering from depression often can't cope. What's your advice to family members?

Family members are a strong support to the person suffering from depression. Family members should understand that depression is an illness, and pressuring the person is not going to improve his condition without proper medical care. It is better to flow with the person with his recovery. One can increase activities with time. Any antidepressants take 6-12 weeks for proper response. Watch for progress and be in touch with attending doctors.Proper precautions are necessary if a person is suicidal. However, small that risk is never leave any medicines with a depressed person. 

Antidepressants do improve mood and activity. Only when an attending doctor gives permission, should a depressed person be alone. In that case, constant supervision is necessary, if not possible then, admit the person. Over the years, various studies demonstrated the superior anti-suicidal activity of Lithium salt. Medical supervision is very necessary during lithium treatment. It requires careful monitoring, and some doctors tend to avoid using it when necessary. There is no other drug that is incisively anti-suicidal. Suicidal thoughts also respond to the infusion of the anaesthetic Ketamine and electroconvulsive therapy. Also, supportive psychotherapy for the very depressed person and CBT for mild to a moderately depressed person is beneficial and have long-term benefits.

How can we prevent it, or keep it at bay?

If a person had an episode of depression, he should bear in mind that it can recur again. Recurrence is dependent on many factors. If a doctor recommends long-term therapy with medications, follow the instructions to the T. There is enough proven evidence for regular medicines to help in keeping relapses under control. These medicines are safe if administered for an extended period. Knowing about the disease of depression from recognised sites would be extremely useful. There’s a lot of free and useful information that is on the website of National Institute of Mental Health. What you don't follow, ask your doctor to explain.

Write your questions down before seeing a doctor. Most patients forget to ask useful and essential information; they only recollect those questions when you are out of the doctor’s cabin which I find crucial to getting the correct treatment. Our job depends a lot on reporting and investigation but it’s tricky because you also are dealing with people who are not at their very best so their families do become important. Regulate sleep. Excessive sleeping or less sleeping does lead to relapse. Living a healthy lifestyle is very helpful in keeping depression under control. Regular exercise and controlling diet are helpful.

Avoid carbohydrate-rich food, if you have diabetes or increased blood pressure, attend to it with a regular check-up. Understanding the cause and treatment of depression is not hard at all. Help can sometimes just be a pill or a telephone call away. I forget his name but someone famous once wrote,"If there be a hell upon earth, it is to be found in a melancholic man’s heart."